Journal of Traumatic Stress Disorders & Treatment ISSN: 2324-8947

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Case Report, J Trauma Stress Disor Treat Vol: 5 Issue: 3

Separation Anxiety Disorder Presenting with Pseudo-Convulsive Episodes: A Case Study

Agata Czyzowicz1* and Brian Greenfield2
1Psychiatry Resident, University of Montreal, Montreal, Quebec, Canada
2Faculty of Medicine, McGill University, Montreal, Quebec, Canada
Corresponding author : Agata Czyzowicz
Psychiatry Resident, University of Montreal, Montreal, Quebec, Canada
E-mail: [email protected]
Received: July 21, 2016 Accepted: August 16, 2016 Published: August 22, 2016
Citation: Czyzowicz A, Greenfield B (2016) Separation Anxiety Disorder Presenting with Pseudo-Convulsive Episodes: A Case Study. J Trauma Stress Disor Treat 5:3. doi:10.4172/2324-8947.1000158

Abstract

A 13-year-old female presented with symptoms resemblingseizures. After several neurologic and psychiatric assessments, a final diagnosis of separation anxiety disorder (SAD) was made.Our case report briefly explains the pathophysiology and clinical presentation of SAD, and how a physician can be fooled by and a typical presentation.
 

Keywords: Anxiety Disorder;depressive

Case

A 13-year-old female was brought to the Emergency Room (ER) by her mother, after experiencing her 4th convulsive-like episode. The 6 minute long event, which was preceded by a headache and dizziness, presented itself with tachycardia, trembling hands and amnesia. After the patient “came back to herself”, her headache persisted for another 10 minutes and was described as pulsating, frontal, bilateral, 10/10 in intensity.
Her first episode occurred two months earlier, while preparing food. A headache appeared suddenly, was accompanied by dizziness and tachycardia, and progressed to a fall, jerking movements of the four limbs and amnesia of the event. The second episode was similar, but proceeded by intense abdominal pain and occurred while the patient was playing outside. The third event was identical to the first one, but occurred while the patient was arguing with a friend. According to the mother, who witnessed that last episode, the patient’s legs were shaking and she did not remember what happened to her, despite having been conscious throughout.
The patient could neither identify the attacks’ sources nor triggers. She “loves” school, has many good friends and gets along with family members. She denied other symptoms of anxiety, such as public speaking, specific phobias or generalized excessive worry. Incontinence, tongue biting, vomiting, focal neurological symptoms or photophonophobia did not accompany the episodes. She reported nightmares and flashbacks, reminiscent of her grandmother’s demise, and denied manic, psychotic and depressive symptoms and stressors exclusive of her grandmother’s death.
Her developmental history was normal. Her mother and sister had panic attacks (including tachypnea, tachycardia, trembling hands), triggered by identifiable stressors and controlled either medically or non-medically.
At follow-up, the patient did all the talking, enjoying fascinating the team with her enigmatic biologic details.
Upon exiting from the team assessment, the mother asked the examiner for a letter requesting homebased learning, noting that the episodes occurred upon arrival to school.

Investigation

At the time of neurologic consultation, she was diagnosed with syncopal convulsions on the basis of her history. Subsequent sleepdeprived electroencephalogram (EEG) revealed no abnormalities.

Mental Status Examination

Jennifer wore a cap and a school uniform. Her mother had poor hygiene, initially answered questions directed to her daughter. The patient had good eye contact, was smiling and collaborative and had no psychomotor abnormalities and a normal speech pattern without pressure. Her mood was euthymic and affect was reactive and neutral (no crying or apparent sadness) even when discussing difficult past events (eg seeing deceased grandmother in her bed), in marked contrast to the mother who was crying at such times. Her thought process was logical and goal oriented. The thought content showed preoccupation with her anxiety and her grandmother’s death in 2007. She denied hallucinations, suicidal and homicidal ideations. Despite fear of having a recurring episode, she did not seem curious as to its etiology, nor insightful into her feelings or behaviors. Her recall of events was overly detailed.

Discussion

According to Margaret Mahler, a child develops its psychological self through a slowly unfolding process. He begins from a primitive cognitiveaffective life, which she labels as sequentially the autistic then symbiotic phases of development, relatively undifferentiated from the mother. He then moves toward awareness of separateness from her and formation of a relationship with her as a differentiated self; the phase of separation/individuation. Patients presenting with SAD are excessively anxious in progressing onto the phase of separation and individuation from the caretaker, whether mother or father [1].
Key items worth investigating when assessing a child with potential SAD include difficulty in attending school during certain grades, a clinging behavior when leaving the caretaker upon departure for school and persistent and excessive worry about possible harm (e.g. illness, injury, death) to parental figures. They also repeatedly complain of physical symptoms (e.g. headaches, stomachaches, vomiting, flu-like symptoms, unexplained pain in various parts of the body, palpitations, dizziness, faintness, nightmares, to name a few) when separation occurs or is anticipated. One also commonly finds a child clinging to a transitional object (e.g. teddy bear or blanket) during the assessment, a parent answering questions posed to the child and a defensive reaction from the parent and/or the child when discussing separation anxiety. Commonly, the father is absent or the mother protects the child from the perceived negative paternal influence (e.g. verbal or physical abuse). Separation anxiety may be triggered by a stressful life event such as moving, school entry or change, a divorce, a medical procedure or the loss of an important family member, friend or pet. It is not uncommon for the child to report nightmares related to separation issues or to have experienced a bona fide underlying medical disorder which had required additional supervision at first diagnosis but no longer. Children with SAD commonly have parents who experienced the same condition during their youth [1-3].
In this particular case, the patient presented most of those symptoms. She reported several physical complaints, which according the mother occurred mainly upon departure for school. As well, the mother often answered questions directed to the patient. The patient’s absence of insight into the origins of her anxiety reflects passivity concerning curiosity, thus avoiding the anxiety associated with emotional awareness. The mother’s persisting grief ten years after the grandmother’s death was interpreted as a multi-generational separation anxiety pattern repeating itself in the present dyad.
Initially, based solely on the patient’s history, the differential was predominantly between a panic disorder and a seizure diathesis. Despite a profile that could reflect separation anxiety, we were fascinated by the patient’s detailed biological account of symptoms, including the perplexing negative EEG result, and suspected that her symptoms instead represented a migraine equivalent.
Several months after the initial assessment, the diagnosis became clear when the patient’s mother requested a note for home schooling. Her request then revealed her true agenda; namely, her intent to keep the identified patient at home with her, consistent with a separation anxiety disorder. The mother’s silence was understood as her wish to conceal this condition from the team and thus avoiding the distress associated with revelation of the disorder and its associated dyadic treatment. We ultimately understood that the patient’s obsessional physical details and atypical presentation camouflaged the real underlying separation anxiety.
Treatment of separation anxiety would be two-fold. An individual therapy would focus on developing self-confidence in the child, while couple/family therapy would help the parent(s) foster autonomy in the child and potentially rediscover a couple life for themselves.

Four Key Points

• The hallmarks of SAD include clinging to parents, excessive worry about separation, difficulty attending school and various, and non-specific physical complaints.
• Most commonly reported physical complaints in patients presenting with SAD are stomachaches, headaches, nausea, vomiting, palpitations and dizziness.
• It is not uncommon for parents of children with SAD to have had a similar pattern of dysfunction in childhood, resulting in multi-generational separation anxiety pattern.
• Separation anxiety can be triggered by stressful life events, such as moving, school entry or changing, a newly diagnosed medical condition, a divorce or death of someone close.

References



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